Challenges in improving mental health literacy at population level
Authors: Claire Henderson
Journal: World Psychiatry (2023)

The expression "mental health literacy" was introduced in 1997 by Jorm et al1, referring to "knowledge and beliefs about mental disorders which aid their recognition, management or prevention". Compared to contemporaneous programmes aiming to reduce stigma and discrimination related to mental illness, this construct reflected a broader and positively framed public mental health goal. However, the concept of mental health literacy does not ignore stigma as a public mental health problem. A more recent definition2 explicitly includes reduced stigma as a component of mental health literacy. One approach to improving mental health literacy has been provided by Mental Health First Aid trainings, mostly conducted in Australia and targeted towards specific professional groups, population subgroups, or disorders. However, while training 1% of the Australian population3 may be an important milestone, given positive evidence for its effectiveness, this coverage is far lower than that achieved by mental health social marketing campaigns in many countries and regions. The cost of mass media once limited the use of social marketing, such that mental health campaigns tended to be brief and showed either limited or no effectiveness4. The advent of social media has allowed organizations to increase their reach and duration for a given spend, and to cover also low- and middle-income countries. Campaigns can deliver more content and drive people towards Internet resources with further content. The clearest example of a public mental health programme which effectively delivered a variety of contents over a long period is Time to Change5, whose social marketing campaign ran in the UK from 2009 to 2021. Although a stigma reduction campaign, this is worth discussing in relation to mental health literacy because of its promotion of supportive behaviors towards people with mental health problems. Market research showed that solely asking people not to stigmatize or discriminate is unsatisfactory; they want to know how they should behave instead. The focus on recognition of signs of common mental disorders, coupled with supportive responses, demonstrates some convergence with the stated objectives of mental health literacy definitions besides stigma reduction. Nevertheless, Time to Change did not cover details about specific disorders. While the campaign included people discussing a variety of disorders, its messaging and evaluation were in relation to "mental illness" or "mental health problems". The evaluation of the outcomes of this campaign focused mainly on stigma and discrimination, but the results illuminate a major challenge in improving population mental health literacy, which is the expansion of the concept of mental illness to include experiences that are not considered as such by professionals. Population survey respondents were asked whether they considered stress and grief to be mental illnesses5. Between 2009 and 2019, the proportion endorsing stress as a mental illness increased from 57.5% to 67.5%; similarly for grief, from 49.3% to 57.9%. This raises the question of whether population mental health campaigns, either targeting stigma or mental health literacy, should try to prevent the medicalization of some experiences as an unintended consequence. The reverse of this issue is the failure to recognize signs and symptoms of common mental disorders due to their normalization. Evidence for this challenge comes from the evaluation of England's first mental health literacy programme, Every Mind Matters. Developed and delivered by Public Health England, Every Mind Matters was launched in October 2019. Its target was to encourage adults in England to take positive action regarding their mental health and thus reduce development of common mental disorders, through a social media marketing campaign promoting digital support resources. The digital resources comprise National Health Service-assured content covering sleep, stress, anxiety, and low mood. There were two bursts of social marketing to drive people to the digital resources before the first national COVID-19 lockdown, while subsequent bursts occurred during the pandemic. The content was therefore further developed to address the mental health challenges created by the pandemic. Web analytics showed that, between October 2019 and February 2021, the Mind Plan for supporting one's mental health was completed over three million times, against a target of one million for the first year. However, in contrast to this high level of usage – and despite small improvements from September 2019 to March 2020 in knowledge of management for stress, depression and anxiety, mental health vigilance, sleep literacy, psychological well-being and self-efficacy – by March 2022 there was a deterioration in all outcomes compared to the September 2019 baseline, except for sleep literacy which was unchanged6. This dramatic example of reduced ability to recognize and act on signs and symptoms of common mental disorders should not be taken as an isolated event. People in difficult social circumstances are more likely to attribute mental distress to these circumstances than to something amenable to professional help-seeking, and responses to medication and psychological therapies are weaker in the presence of such circumstances7. Public mental health organizations must acknowledge the impact of these circumstances and work to address them. The development of Every Mind Matters highlighted two further challenges in improving population mental health literacy. One is differential demand for literacy components. Following a pilot study, revisions were made to the digital resources and campaign before the launch, shifting from promoting recognition of signs and symptoms to evidence-based actions to protect and improve mental health. The feedback indicated that people wanted easier access to information on actions, and did not want to first read content promoting recognition. The other challenge is avoidance in relation to severe illness. Content in addition to the initial four problems (sleep, stress, anxiety, and low mood) was planned, including on obsessive-compulsive disorder, panic, social anxiety and the impacts of trauma, but was not added due to funding decisions. Psychosis was not considered in scope for Every Mind Matters, as the National Health Service recommendation emphasizes the need to seek help from health professionals for this condition. The immediate issue arising is that excluding disorders from a campaign named Every Mind Matters risks alienating some. However, market research also indicated that fear of psychosis is such that inclusion of content about it might reduce use of the site. This would be problematic for future programmes wishing to include information on psychosis, given the severity of the disorder and its raised incidence in communities experiencing high levels of adversity8. It seems that Time to Change has been insufficiently effective in relation to the stigma towards psychosis, to the extent that a literacy campaign cannot include it without negative consequences. There is evidence from newspaper content analysis of a differential outcome of Time to Change with respect to diagnosis9. The probability of an article on schizophrenia being rated as stigmatizing was not different for 2008 and 2019, whereas for depression the probability fell between these years. Thus, while stigma reduction may be considered a component of mental health literacy, stigma presents a barrier to its improvement. A specific focus on psychosis may be needed, following the WPA's Open the Doors programme. Improving mental health literacy thus faces several challenges, which may be amenable to the careful development, over several years, of a programme which is inclusive while paying attention to the need to reduce the risk of avoidance due to fear; acknowledges the impact of social problems such as lack of economic opportunities and discrimination on mental health; and avoids medicalization without discouraging help-seeking.